Transdiagnostic emotion-focused therapy

1. Introduction

Version followed: EFT-T as set out by Ladislav Timulak and Daragh Keogh (Trinity College Dublin). The sources are the transdiagnostic formulation paper (Timulak & Keogh, J Contemp Psychother 2020; abstract and reference list), the 16–20-session protocol of the Trinity College Dublin feasibility RCT (Timulak et al., HRB Open Research 2020; full text), and the published descriptions of the APA clinical guide (Timulak & Keogh 2022) and of Transforming Emotional Pain in Psychotherapy (Timulak; 2nd ed. listed for 2027). Generic EFT task procedures follow Elliott & Greenberg (2016; full text). The full texts of the 2022 book and of Timulak (2015) are not drawn on. EFT-T-specific task detail from those books is tagged [uncertain].

Atlas check: the founders (Timulak, Keogh) and the name EFT-T are confirmed [source: Timulak & Keogh 2020; Timulak et al. 2020].

EFT-T is a single, modular individual therapy for depression, anxiety and related problems (OCD and trauma/stressor-related disorders) [source: Timulak & Keogh 2020 abstract]. It combines elements of several disorder-specific EFT adaptations (depression, generalised anxiety, social anxiety, complex trauma) into one transdiagnostic framework [source: Timulak et al. 2020]. It works at two levels:

the symptom level: modules for clusters such as worry, rumination, self-criticism or perfectionism, obsessions, flashbacks and overwhelming distress;
the shared vulnerability: "Core Pain", a chronic painful feeling that combines, in varying mixes, sadness/loneliness, shame and fear, shaped by the client's history [source: Timulak & Keogh 2020 abstract; APA book description].

How change happens: symptoms are seen as signs of difficulty processing core pain. Triggers in the client's interactions activate that pain. The client either becomes distressed or avoids it, emotionally or behaviourally, and often "self-treats" it in problematic ways (for example, worrying at or criticising themselves) [source: Timulak et al. 2020].

Change comes in two steps:

The client first builds coping resources and sees their own agency in producing symptoms.
The client then accesses and tolerates the core pain, names the unmet needs in it (connection, validation, protection), and generates adaptive emotions (compassion and protective anger) that answer those needs. This transforms the pain [source: Timulak et al. 2020; Timulak & Keogh 2020; Timulak 2nd ed. description].

2. Framework

Format. Individual therapy, 16–20 sessions [source: Timulak et al. 2020]:

the therapist aims to finish at session 16;
up to four further sessions may be added if the client is still clinically distressed on OASIS/ODSIS and explicitly wants to continue.

The protocol does not state frequency or session length. Weekly sessions of about 50–60 minutes are standard EFT practice [uncertain]. In the trial, therapists were EFT-certified to International Society for Emotion-Focused Therapy (isEFT) standards and received extra EFT-T training and monthly supervision. Adherence was rated with the PCEPS-EFT [source: Timulak et al. 2020].

Case conceptualisation map (used throughout). Each element is filled in collaboratively [source: Timulak et al. 2020; Timulak & Keogh 2020; mapping layout from Timulak 2015/2022 recalled: uncertain]:

Triggers: the situations, especially interpersonal ones (rejection, criticism, loss, threat), that set off painful feelings.
Global distress / symptoms: depression, anxiety, panic, rumination, obsessions, flashbacks.
Self-treatment: what the client does to themselves:
- self-worrying (scaring oneself to prevent danger);
- self-criticism or perfectionist pressure;
- self-interruption (shutting feelings down).
Avoidance: behavioural avoidance (situations, people) and emotional avoidance (numbing, distraction).
Core pain: the client's own blend of loneliness/sadness, shame and fear, located in key biographical experiences.
Unmet needs: connection/love, validation/acceptance, safety/protection.
Adaptive responses that answer the needs: compassion (from self or an imagined caring other) and protective (boundary-setting) anger.

Phases. The protocol names four foci. Timulak's 2nd edition describes four steps of transformation: tolerate pain, identify core pain, recognise unmet needs, respond with compassion and protective anger [source: Timulak et al. 2020; Timulak 2nd ed. description]. The session ranges below are approximate and are my synthesis [synthesis].

Phase	Goals	Typical sessions	Move on when
A. Relationship and conceptualisation	Attuned, compassionate bond; assessment; collaborative case conceptualisation; agree on focus; teach about emotion	1–3	Client feels understood; triggers, symptoms and a first guess at core pain are named; client agrees to experiential work
B. Symptom-level work and building capacity	Regulate overwhelming distress; use chair tasks for self-worrying, self-criticism and self-interruption, showing the function and cost of each symptom-producing process; reduce avoidance	about 3–8 (runs alongside C)	Client can stay with painful feeling without being flooded or shutting down, and sees their agency in generating symptoms [source: Timulak et al. 2020]
C. Transforming core pain	Access core pain; articulate unmet needs; generate compassion and protective anger, usually in empty-chair or compassionate self-soothing work; let go of / grieve what was not received [grief step: uncertain]	about 6–15	Client shows less felt shame or fear and more self-compassion and assertive self-protection; a new view of self and other
D. Consolidation and ending	Bridge in-session change to everyday life; review the formulation; plan for relapse; end at 16, or extend to 20 if needed	14–16 (up to 20)	Planned ending; OASIS/ODSIS review [source: Timulak et al. 2020; 2nd ed. ch. 9 title]

The phases overlap. Work is marker-driven: the therapist moves to whatever task the client's in-session marker signals, keeping the formulation in mind [source: Elliott & Greenberg 2016]. The model's overall order is coping first, then core-pain transformation [source: Timulak et al. 2020].

3. Guiding principles

From Elliott & Greenberg (2016), EFT's general practice and emotion-change principles, which EFT-T inherits:

Empathic attunement. Track the main meaning, the most poignant feeling and what is unclear or emerging. In practice: reflect the live edge, not the story.
Therapeutic bond. Convey understanding, acceptance/prizing and presence. Prizing matters most when the client is vulnerable. In practice: warmth goes up exactly when shame shows.
Task collaboration. Agree goals and tasks, and explain the rationale. In practice: propose a chair task only after giving a reason the client can accept.
Emotional deepening through tasks. Keep the foci in view and return gently to key tasks. In practice: when the client drifts off topic, name it and invite a return.
Self-development. The client is the expert on themselves and controls how much risk they take. In practice: offer, don't push; the client can decline any exercise.
Shifting processing modes. Move between attending, bodily sensing, naming feelings, voicing needs and reflecting. In practice: when the client is all head, guide them to the body; when all affect, help them make meaning.
Awareness. Feel and name emotion, not just talk about it. In practice: ask what is felt right now and where in the body.
Expression. Help constricted primary emotion come out. Venting secondary emotion is not the aim. In practice: stop repeated angry complaining and look for the hurt underneath.
Regulation. Calm under-regulated emotion and evoke over-regulated emotion. In practice: adjust the client's arousal to a workable distance before deepening.
Reflection. Make narrative sense of emotion once it has been aroused. In practice: after an intense chair task, leave time to say what it meant.
Transformation. Change maladaptive emotion with adaptive emotion, for example shame or fear met by anger or self-compassion. Asking what is needed opens the way to adaptive emotion. In practice: once core pain is felt, ask what the hurting part needs.
Emotion types. Distinguish primary adaptive, primary maladaptive, secondary reactive and instrumental emotions. In practice: work with each type differently: follow adaptive emotion, transform maladaptive, explore past secondary, and gently name instrumental.

Specific to EFT-T [source: Timulak & Keogh 2020; Timulak et al. 2020; APA book description]:

Target the vulnerability, not only the diagnosis. In practice: across comorbid problems, look for the one shared core pain.
Modularity. Choose symptom-level tasks by the clusters present (worry, rumination/self-criticism, perfectionism, obsessions, trauma symptoms). In practice: there is no fixed session order; match the module to the marker.
Agency in symptoms. Use experiential tasks that let the client feel how they produce their own distress, what it is for (protection) and what it costs. In practice: turn "anxiety happens to me" into "this is how I scare myself, and why".
Coping before depth. Build the capacity to tolerate pain before evoking it fully. In practice: don't open core shame in a client who is still flooding.
Pain points to needs. Core pain carries unmet needs for connection, validation and protection. In practice: every time core pain appears, ask about the need.
Compassion and protective anger as antidotes. These are the two adaptive responses EFT-T aims to generate. In practice: compassion answers loneliness and shame; protective anger answers violation and fear.
Formulation-guided. Keep the conceptualisation map live and shared. In practice: reuse the client's own words for triggers and pain in each session.
Bridge to everyday life. In-session change has to be carried into daily life [source: 2nd ed. TOC ch. 9]. In practice: end sessions by noticing where the new response could show up this week.

Timulak's 2nd edition gives a chapter to the therapeutic relationship promoting emotional transformation [source: Timulak 2nd ed. TOC]. The relationship is treated as an active agent: the therapist's own compassion is a model for the client's self-compassion [content of that chapter: uncertain].

4. Intervention inventory

The protocol and abstracts name the elements of EFT-T but not their steps. Steps below come from three places, each tagged:

generic EFT task models [source: Elliott & Greenberg 2016];
EFT-T-specific adaptations recalled from Timulak (2015), Timulak & McElvaney (2017) and Timulak & Keogh (2022) [uncertain];
my own glue [synthesis].

All example language is illustrative unless quoted.

4.1 Collaborative case conceptualisation

Purpose / when: Sessions 1–3, then kept up to date throughout. It tells you which symptom modules to use and what the core pain and needs are [source: Timulak et al. 2020 ("firm case conceptualisation" as first focus); Goldman & Greenberg 2015 cited].
Steps:
1. Take a standard intake, including a risk assessment, and obtain baseline OASIS, ODSIS and CORE-OM (the trial's outcome measures; administer under their own terms, do not reproduce items).
2. Ask for 2–3 recent episodes in which symptoms peaked. For each, slow down to the trigger: what happened, especially with other people.
3. Track what the client did to themselves next: worrying, criticising, shutting down, avoiding.
4. Follow the feeling underneath with empathic exploration. Listen for loneliness/sadness, shame and fear, and for biographical echoes of each.
5. Draft the map (triggers, then symptoms/global distress, self-treatment, avoidance, core pain, unmet needs) on paper. Use the client's own words and check each part for fit.
6. Agree a focus, for example "feeling not good enough and alone with it", and explain that the work will move from coping with symptoms to the underlying pain [synthesis for steps 2–6, built on the components in Timulak et al. 2020].
Example language (illustrative): "When your manager didn't reply, it sounds like the first thing was a jolt in your stomach, then the 'what if they fire me' spiral. And underneath it, something like feeling small and on your own. Does that fit?"
Watch for: a formulation that is too intellectual. Core pain should be felt in the room at least briefly. The map is working if the client starts to recognise the sequence as it happens ("I'm doing the worry thing again").

4.2 Empathic responding (understanding and exploration)

Purpose / when: Every session. This is the basic medium of the therapy and the main way to deepen experience [source: Elliott & Greenberg 2016].
Steps: Use the response modes in a mix:
1. Empathic understanding: simple reflections and brief acknowledgments.
2. Empathic exploration:
  - evocative reflections (vivid, image-rich wording);
  - exploratory questions ("what is that like inside?");
  - fit questions;
  - empathic conjectures that name a feeling just ahead of the client.
3. Empathic affirmation: warm prizing when the client is vulnerable.
4. Aim each response at the most poignant or emerging edge of what the client said.
Example language (illustrative): "So hearing that, it's not just irritation, it's more like a sinking: here I go again, the one nobody picks?"
Watch for: reflections that only summarise content. It is working when the client slows down, speaks from inside the feeling, and corrects or adds detail.

4.3 Experiential teaching, rationale and task structuring

Purpose / when: Before introducing chair work, when the client is puzzled by the method, and at the formulation stage [source: Elliott & Greenberg 2016 (process guiding, experiential teaching, task structuring)].
Steps:
1. Explain briefly that emotions carry information and needs.
2. Explain that some feelings cover deeper ones, and that tasks help reach and change the deeper feelings.
3. Describe what you are about to propose and why, and how the client can stop at any point.
4. Set up the chairs only with the client's agreement.
Example language (illustrative): "I'd like to try something that might feel a bit odd: putting the worrying part of you in that chair, so we can see how it works on you and what it's trying to protect you from. You can stop any time. Willing to try?"
Watch for: compliance without buy-in. Watch too for embarrassment about chair work, which you can normalise and work with (see 5).

4.4 Regulating global distress (capacity-building)

Purpose / when: When the client is flooded, panicky or in undifferentiated distress, or before deep work with a fragile client. The aim is to build the capacity to be with painful emotion [source: Elliott & Greenberg 2016 (regulation principle); Timulak et al. 2020 (internal coping resources); Timulak 2nd ed. ch. 6 title].
Steps:
1. Offer a calm, slow, validating presence. Lower your own voice and pace.
2. Validate the distress and its sense.
3. Guide breathing and grounding: feet on the floor, noticing the chair, breathing out slowly.
4. Find a working distance: describe the feeling as an object at a distance, or imagine putting it in a container.
5. Help the client name the trigger and what it touched in them.
6. Draw on the client's own self-soothing, for example how they would comfort a friend.
7. Once the client is regulated, decide together whether to go deeper or stop for today.
Example language (illustrative): "Let's slow right down. Feel your feet on the floor. Breathe out a little longer than you breathe in. The feeling is big. Can you picture it sitting a few feet in front of you, where we can both look at it?"
Watch for: using regulation to avoid feeling for good. In EFT-T, regulation prepares for accessing pain; it is not the endpoint. It is working when the client can describe the feeling instead of being swept by it.

4.5 Clearing a space

Purpose / when: When the client is overwhelmed by many concerns or cannot settle. Elliott & Greenberg list it as a marker-task pairing [source: Elliott & Greenberg 2016, named only; steps from the focusing tradition: uncertain].
Steps:
1. Invite inward attention.
2. Ask what stands between the client and feeling all right.
3. As each concern comes up, acknowledge it and imagine placing it at a comfortable distance.
4. Check the bodily sense of space that remains.
5. Choose one concern to work with, or rest in the cleared space.
Example language (illustrative): "What's in the way of feeling okay right now? ... Good. Can you set that one down somewhere nearby, not gone, just put down? What else is there?"
Watch for: the client suppressing feelings rather than distancing them. It is working when the client reports a felt sense of relief or space.

4.6 Focusing on an unclear felt sense

Purpose / when: Marker: the client is vague, confused or cannot name what they feel [source: Elliott & Greenberg 2016].
Steps:
1. Invite the client to attend inwardly, in the body, with curiosity.
2. Let a felt sense form around the issue.
3. Find a word or image that fits it (a handle).
4. Check the handle against the felt sense, adjusting until it fits.
5. Ask what the feeling needs or is about.
6. Receive whatever comes.
Resolution: new meaning and a bodily release [source: Elliott & Greenberg 2016].
Example language (illustrative): "Take a moment and go inside, maybe to the chest or stomach. What's there when you think about your sister? ... Is there a word that fits it? 'Heavy'? 'Pushed away'? Check it against the feeling."
Watch for: the client only thinking about the feeling. A shift in breathing or posture, or an "aha", signals progress.

4.7 Systematic evocative unfolding of a problematic reaction

Purpose / when: Marker: the client is puzzled by their own reaction ("I don't know why I burst into tears") [source: Elliott & Greenberg 2016].
Steps:
1. Confirm the puzzling reaction.
2. Re-evoke the scene vividly, in the present tense, with sensory detail.
3. Find the exact moment the reaction started and the precise trigger.
4. Explore how the client took in that trigger: its meaning.
5. Link situation, meaning and emotion.
6. Widen to what this says about the client's way of functioning, which often leads to core pain.
Resolution: a new view of how the self works [source: Elliott & Greenberg 2016].
Example language (illustrative): "Let's go back there. You're at the table, she says 'fine, whatever'. What did you see on her face at that exact moment? ... And what did 'whatever' mean to you, inside?"
Watch for: the trigger is usually tiny and interpersonal. A good unfolding often uncovers shame or loneliness, which feeds straight into the formulation.

4.8 Self-worrying two-chair dialogue (worry, anxious anticipation, obsessional doubt)

Purpose / when: Marker: the client worries, anticipates catastrophe, or reports anxiety they can't explain. The task lets the client feel how they scare themselves, what the worry protects them from (core pain), and what it costs [source: APA book description names self-worrying; Timulak et al. 2020 (function and cost of symptom-producing processes); task form recalled from Timulak & McElvaney 2017 and Watson & Greenberg 2017: uncertain].
Steps:
1. Set up two chairs: the Worrier and the Experiencing self.
2. In the Worrier chair, the client enacts the worrying aloud, directly to the self ("you"), making it vivid: what to fear, what could go wrong, what the self must do.
3. Switch to the Experiencing chair: "What happens inside when it says this to you?" Help the client name the anxiety and the bodily tension.
4. Return to the Worrier: "What are you trying to protect her from?" This usually reveals the feared core pain (rejection, humiliation, being alone) and the Worrier's protective intent.
5. Back in the Experiencing chair, help the client feel the cost of being worried at like this and voice what they need from the Worrier: to ease off, to trust, to stop.
6. Explore whether the Worrier can soften. Then follow the core pain that has opened up into the core-pain tasks (4.13 to 4.16).
Example language (illustrative): Worrier chair: "Go ahead, worry at her the way you do. What do you warn her about?" Experiencing chair: "Hearing that, what happens in your body?" Back to the Worrier: "What's the worst thing you're trying to save her from?"
Watch for:
- Speeding-up loops: the client repeats the worries without contacting feeling. Slow down and ask about the effect.
- The Worrier's protective function: acknowledge it rather than attacking the Worrier.
- Signs it's working: the client experiences "I do this to myself"; anxiety turns into a clearer underlying feeling (fear of being alone, shame); an assertive "stop" or a softened Worrier.
Obsessions [uncertain: EFT-T groups obsessions with worry-type self-treatment per Timulak & Keogh 2020 scope; detailed variant]: the same structure can enact the doubting or checking demand ("you must make sure, or else..."). Explore its feared consequence and the shame or fear underneath. Do not argue with content [synthesis].

4.9 Self-critical two-chair dialogue (incl. perfectionism and self-critical rumination)

Purpose / when: Marker: a conflict split, where one part of the self criticises, coerces or puts down another [source: Elliott & Greenberg 2016]. EFT-T uses it as a cluster-level strategy for depressive self-criticism, rumination and perfectionism [source: APA book description].
Steps [source: Elliott & Greenberg 2016, adapted]:
1. Name the split and invite the client to be the Critic in one chair, speaking to the self in the other chair.
2. Make the critic's messages specific and voice them as "you", including tone and gestures.
3. Switch: "What is it like to hear this?" Follow the immediate reaction. Expect secondary hopelessness or collapse first, then deeper shame or sadness.
4. Alternate the chairs, helping each side express thoughts, feelings and wants in live contact.
5. When core pain is felt in the self chair, help the client express the unmet need to the Critic (to be accepted, to be less harsh).
6. Return to the Critic and ask how it responds to that need. Give it a chance to soften once the client is ready [Elliott & Greenberg 2016].
7. If the critic is perfectionist, also explore what it fears would happen without the pressure. Its protective fear is often fear of failure or rejection [synthesis; perfectionism module named in APA book description, detail: uncertain].
Resolution: the critic softens (into concern, sadness or compassion) and the two sides integrate [source: Elliott & Greenberg 2016].
Example language (illustrative): "Come over here and be the part that tears him down. What do you say to him? ... Come back. When he says 'you're pathetic', what happens?" Later: "Tell him what you need from him."
Watch for:
- Critic reprisals and impasse: Elliott & Greenberg's case had "self-critical reprisals" that led to anguish, which was later resolved with self-soothing work. This means a self-critical impasse is a cue to move to compassionate self-soothing (4.15).
- Signs it's working: the self stands up, or the critic's tone shifts.

4.10 Self-interruption two-chair enactment (emotional avoidance)

Purpose / when: Marker: the client blocks emotional experience or expression, for example tears coming up and then tightening [source: Elliott & Greenberg 2016]. EFT-T names self-interruption as a cluster-level strategy [source: APA book description]. Use it for numbing, depressive shutdown, and blocked grief or anger.
Steps [source: Elliott & Greenberg 2016]:
1. Notice and name the interruption as it happens.
2. Invite the client to enact the interrupter in the other chair: physically (pressing down, choking off), metaphorically (a wall, a lid) or verbally ("don't cry, it's pointless").
3. Help the client feel themselves as the agent of the shutdown and explore how and why the interrupter does it (often protection from being overwhelmed or rejected).
4. In the self chair, explore what it is like to be shut down. Support the client in challenging the interrupter.
5. Allow the blocked emotion to be expressed, then work with it (often it is core pain).
Example language (illustrative): "Your jaw just tightened. Could you come here and do that to yourself, show me how you stop the tears? ... What do you say to her to make her stop?" Then: "Come back. How is it to be squeezed like that?"
Watch for: pushing past a protective block too fast in a client with limited capacity. Respect the interrupter's function. It is working when the client says "I'm doing this" and lets a fuller emotion through.

4.11 Working with behavioural avoidance

Purpose / when: The formulation shows the client avoiding triggering situations or people (social withdrawal, procrastination, avoiding conflict). EFT-T includes behavioural avoidance in the formulation [source: Timulak et al. 2020]. The detailed procedure is [uncertain]. The steps below are my synthesis [synthesis].
Steps:
1. Map the avoidance onto the conceptualisation: which core pain it keeps away.
2. Explore its function and cost experientially. The client can enact the avoiding part in a chair ("stay home, you'll only embarrass yourself"), much as in 4.8, and feel its effect.
3. Once core pain has been transformed in session, agree small, client-chosen experiments in daily life that test the new response (for example, saying what they need).
4. Review what happened emotionally the next session.
Example language (illustrative): "So the part that keeps you away from the party is protecting you from that awful feeling of being left on the edge. What does it cost you to always obey it?"
Watch for: turning this into graded exposure without emotional processing. That is not EFT-T, although combining the two is a clinician's choice [synthesis]. It is working when avoidance falls as shame or fear eases.

4.12 Trauma-related symptoms: retelling and imaginal work

Purpose / when: Trauma/stressor-related symptoms (flashbacks, intrusive memories), which EFT-T covers [source: Timulak & Keogh 2020; Timulak et al. 2020 (flashbacks)]. EFT-T draws on Paivio & Pascual-Leone (2010) and the narrative markers (untold story, same old story) listed in Elliott & Greenberg 2016 [source]. The specific EFT-T trauma procedure is [uncertain].
Steps [synthesis based on EFT principles]:
1. Make sure the client is stable, the relationship is safe, and the client can regulate (4.4).
2. Invite the client to retell the event slowly, in the first person and present tense, at a pace they control. Pause at hot spots.
3. Empathically reflect and explore what the moment meant: the core pain of terror, shame or aloneness.
4. Articulate the need that was unmet (protection, someone to come).
5. Move into compassion and protective-anger work (4.14 to 4.16). This may include an imagined protective figure or an empty-chair confrontation of the perpetrator.
6. Close with grounding.
Example language (illustrative): "Only as much as feels manageable. Take me to the moment the door opened. ... What did that little girl need right then?" (The Timulak training video shows work with a client's traumatic birth experience that links the trauma to core pain and unmet needs and then evokes compassion [source: CPCAB video description].)
Watch for: dissociation or flooding: stop and regulate. Assess for active current danger before trauma work (see 5). It is working when the memory loses its intensity and the client reports a new self-view, for example from "it was my fault" to "I needed protecting".

4.13 Accessing core pain (emotional deepening)

Purpose / when: After symptom-level work has opened onto deeper feeling, and the client can tolerate it. This is the gateway to transformation [source: Timulak et al. 2020; Timulak 2nd ed. steps 1–2 and ch. 6 title].
Steps:
1. Follow the EFT deepening sequence: undifferentiated distress, then secondary reactive emotion (frustration, hopelessness), then primary maladaptive emotion, then core pain [source: Elliott & Greenberg 2016; core.ac.uk chapter abstract].
2. Use evocative reflections and empathic conjectures to stay with the most painful part, linking it to the biographical moments in the formulation.
3. Help the client name the blend in their own words (lonely and unwanted; worthless and defective; terrified and unprotected).
4. Validate how it hurts and slow down. Let it be felt in the body, at a tolerable intensity.
Example language (illustrative): "Underneath the anger at your partner there's something rawer. Like: once again, I don't matter to anyone. Is that it? ... Stay with that a moment. Where do you feel it?"
Watch for: secondary hopelessness passed off as core pain. Core pain feels specific and old, often with a quieter, deeper tone. It is working when the client says, often tearfully, "that's it, that's what it always is."

4.14 Articulating the unmet need

Purpose / when: As soon as core pain is felt. The need is the pivot to adaptive emotion [source: Timulak et al. 2020 (needs for connection, validation, protection); Elliott & Greenberg 2016 (focusing on what is needed helps access adaptive emotion); Timulak 2nd ed. step 3].
Steps:
1. Ask from inside the pain what the hurting part needs, or needed then.
2. Help the client state it as a direct first-person want, ideally addressed to the relevant other or to the critic ("I needed you to see me").
3. Validate the need as legitimate.
4. Notice the client's emotional response to stating it. A sense of entitlement often brings up assertive anger or sadness [source for step 4: EFT emotion-change principle; detail synthesis].
Example language (illustrative): "From that lonely place, what do you need? Tell him: 'I needed...'"
Watch for: the need being dismissed straight away ("there's no point wanting that"). That is an interruption or critic marker (4.9, 4.10). It is working when the client voices the need with conviction.

4.15 Compassionate self-soothing (generating compassion)

Purpose / when: Marker: stuck, intense anguish or an unmet existential need for love or validation [source: Elliott & Greenberg 2016]. In EFT-T, compassion is one of the two adaptive responses that transform core pain, especially loneliness and shame [source: Timulak & Keogh 2020 abstract].
Steps [source: Elliott & Greenberg 2016; EFT-T variant recalled from Timulak 2015/2022: uncertain]:
1. Deepen to core pain and the unmet need (4.13, 4.14).
2. Set up a two-chair process. The needy part (often the child self, or the self imagined as a friend or child) sits in one chair. In the other, the client becomes a comforter: their own nurturing adult self, an idealised parent, or a caring person from their life.
3. Ask the comforter what they see and feel towards the one who is hurting, and what they want to say or do.
4. Return to the hurting chair: "How is it to receive that?" Help the client let it in.
5. If compassion can't be generated, try other sources: a different caring figure, the therapist's own compassion stated directly, or a pet or child image [synthesis].
Example language (illustrative): "Could you come over here and be someone who really loves that little boy, maybe your grandmother? Look at him sitting there, so alone. What do you feel towards him? Tell him." Then: "Come back. Can you take that in?"
Watch for:
- Hollow, formulaic soothing. It needs to be felt, not said.
- Shame at receiving care. Treat this as a marker; explore it gently.
- Signs it's working: softening, relief, a quiet self-acceptance, and less shame afterwards.

4.16 Empty-chair work for unfinished business; generating protective anger

Purpose / when: Marker: lingering unresolved bad feelings towards a significant other, expressed with high involvement [source: Elliott & Greenberg 2016]. In EFT-T this is the main route to protective anger: assertive, boundary-setting anger at violation, which answers the need for protection and validation, especially when fear and shame dominate [source: Timulak & Keogh 2020 abstract (protective anger); use of the empty chair for this recalled from Timulak 2015/2022: uncertain].
Steps [source: Elliott & Greenberg 2016, adapted]:
1. Invite the client to imagine the other in the empty chair and to describe them: posture, expression.
2. Ask the client to tell the other what it was like for them, expressing complaints and differentiating feelings: hurt/sadness and anger, separately.
3. When needed, have the client enact the other briefly so the impact of the other's stance (rejecting, dismissive) can be felt. Then return to the self chair.
4. Help the client articulate the unmet need to the other.
5. Support primary assertive anger with posture, voice and "I" statements, and set the boundary: what was not okay, and what the client deserved.
6. Let the client's view of the other shift: holding them accountable, or understanding or forgiving them. Either counts as resolution [Elliott & Greenberg 2016].
Example language (illustrative): "See your father there. What do you want him to know about what it was like? ... Say it again, and let your voice carry it: 'It was not okay to...'. What did you deserve?"
Watch for:
- Rejecting or contemptuous anger (secondary or instrumental) rather than protective anger; guide back to the violation and the need.
- Collapse into fear when facing an abuser; increase distance, place a protector in the room, or start with compassion.
- Do not push towards forgiveness.
- Signs it's working: the client sits up and speaks firmly; shame turns into "I didn't deserve that"; fear eases.

4.17 Grieving and letting go of what was not received

Purpose / when: After compassion or protective anger has been generated: accepting the loss of what was never provided, or never will be, from the other [recalled from Timulak 2015 as part of the transformation sequence: uncertain; Elliott & Greenberg 2016 list sadness as a primary adaptive emotion].
Steps [synthesis]:
1. Reflect the poignancy of what the client deserved and missed.
2. Allow adaptive sadness, which is different from the old despair, to be felt and expressed.
3. Invite the client to say goodbye to the hope, or to say what they will now give themselves or seek elsewhere.
Example language (illustrative): "It sounds sad, and different from before: she won't ever be the mother you needed. What's that like to know?"
Watch for: relapse into hopeless depression. This sadness should feel clean and relieving. It is working when the client turns towards present relationships and self-care.

4.18 Meaning-making and narrative work

Purpose / when:
- Markers: "same old story", "empty story", "untold story", "healing story", and "meaning making" under high distress [source: Elliott & Greenberg 2016, named only; steps not given: uncertain].
- Use after intense emotional work, to consolidate a new self-narrative that the formulation predicts (for example, from defective to worthy of care).
Steps [synthesis]:
1. Invite the client to reflect on what happened in the task.
2. Help them put the new experience into words.
3. Link it back to the conceptualisation and to other episodes in their life.
Example language (illustrative): "What did you learn about yourself just now? How does it change the story of 'I'm the one nobody wants'?"
Watch for: premature intellectualising before feeling has settled.

4.19 Alliance dialogue (rupture repair)

Purpose / when: Alliance rupture markers: withdrawal, irritation with the therapist, or disagreement about tasks [source: Elliott & Greenberg 2016, named as a marker; steps synthesis].
Steps [synthesis]:
1. Name what you noticed, non-defensively.
2. Invite the client to say what is happening between you.
3. Validate it and own your part.
4. Explore the client's feelings, which may echo core pain (not being heard).
5. Renegotiate tasks and goals.
Example language (illustrative): "I noticed you went quiet when I suggested the chair. I may have pushed. What happened for you?"
Watch for: repairs that stay at the surface. A repaired rupture can itself be a corrective experience of core pain being met [synthesis].

4.20 Bridging to everyday life (awareness homework)

Purpose / when: From the middle phase on, to carry in-session change into daily life [source: Timulak 2nd ed. ch. 9 "Enhancing Client Engagement and Bridging Therapy and Everyday Life"; Elliott & Greenberg 2016 (awareness homework)]. The chapter content is [uncertain].
Steps [synthesis]:
1. At the end of a session, ask where the old sequence (trigger, then worry or criticism, then pain) is likely to show up this week.
2. Agree one noticing task, for example catching the Worrier in action, or a compassion or assertion practice.
3. Review it at the start of the next session as material for experiential work.
Example language (illustrative): "This week, just notice when the critic starts up. No need to change it. See what you feel just before."
Watch for: homework turning into a performance test (see non-adherence in 5).

4.21 Outcome review, extension decision and ending

Purpose / when: Around session 14–16 [source: Timulak et al. 2020].
Steps:
1. Re-administer OASIS, ODSIS and CORE-OM.
2. Review the conceptualisation map with the client: what has changed in triggers, self-treatment and core pain.
3. If the client is still clinically distressed and explicitly wants to continue, add up to four sessions with a clear focus.
4. Otherwise, end at 16.
5. Plan for relapse: early signs, and the compassion and assertion responses to call on [steps 2 and 5: synthesis].
Example language (illustrative): "Let's look back at the map we drew in the first weeks. What's different now when the trigger hits?"
Watch for: core pain activated by the ending (abandonment). Process the ending itself emotionally.

5. Handling problems

Timulak's 2nd edition has a chapter on "working with difficulties in the therapeutic process" [source: TOC], but its content is [uncertain]. Guidance tagged [source: Elliott & Greenberg 2016] comes from the opened generic EFT text. The rest is my synthesis.

Suitability and risk (screen first). Elliott & Greenberg list poor fits for EFT:
- psychotic processes;
- impulse-control or antisocial patterns;
- crisis needs such as acute suicidality or ongoing abuse;
- clients who reject inner exploration.
Refer these on or stabilise first [source: Elliott & Greenberg 2016]. Assess suicide and self-harm risk at intake and whenever core pain deepens: ask directly, make a collaborative safety plan, involve supports, and counsel on lethal means (secure storage, removal) under standard practice. Postpone deep core-pain or trauma work while risk is acute [synthesis].
Overwhelm or flooding (too much emotion). Begin with a safe, calming, validating presence, then regulation strategies [source: Elliott & Greenberg 2016]. In practice:
- stop deepening;
- ground the client (4.4);
- increase working distance, for example from the chair to the therapist's voice, or to talking about the feeling rather than from inside it;
- spend more sessions in Phase B.
Do not end a session flooded. Leave 10 minutes to settle [synthesis].
Too little emotion / intellectualising. Use awareness and expression work, unfolding, and self-interruption enactment, and target numbing [source: Elliott & Greenberg 2016]. If the processing is purely conceptual or externalised, shift towards experiencing ("what do you feel as you tell me this?") [source: same].
Stuck at secondary emotion (endless complaint, hopelessness, anxiety without depth). Name the loop gently and conjecture what lies underneath. Use self-worrying or self-critical dialogue to show the client's agency [synthesis; agency principle from Timulak et al. 2020].
Critic won't soften / impasse. Elliott & Greenberg's case shows self-critical reprisals leading to anguish, resolved through self-soothing work [source: Elliott & Greenberg 2016]. So:
- switch to compassionate self-soothing (4.15);
- or explore the critic's protective fear;
- or check whether the critic is an introjected significant other, and if so move to the empty chair (4.16) [last option: synthesis].
Client can't generate compassion (feels contempt or nothing towards the hurting self). Try other sources of compassion (an imagined caring other, the client towards a child, the therapist's own compassion said directly). Explore the shame blocking it as a self-interruption marker. Go slowly [synthesis].
Fear blocks protective anger (especially towards abusers). Increase distance:
- put the perpetrator far away or behind glass;
- have the client imagine a protective ally;
- start with the client's anger on behalf of their child self;
- or work with compassion first.
Never encourage confrontation in real life without safety planning [synthesis].
Resistance to chair work (embarrassment, "this is silly"). Give the rationale again (4.3). Offer a lighter version: talking to the image of the other while staying in one chair, or the client describing the critic while the therapist voices it [therapist voicing: uncertain, not a documented EFT-T procedure]. Respect a refusal and keep working through empathic exploration and focusing, which are full EFT methods in their own right [synthesis].
Non-adherence to homework. Treat it as information about the formulation: perhaps a critic ("you'll do it wrong"), avoidance, or low priority. Explore it experientially rather than correcting it, and reduce homework to noticing [synthesis].
Ruptures. Use the alliance dialogue (4.19). Ruptures often re-enact core pain (feeling unseen, controlled or judged), so repairing them is itself therapeutic. Track whether a task was pushed too hard [synthesis; rupture as a marker: Elliott & Greenberg 2016].
Many problems at once (high comorbidity, many concerns). Clear a space (4.5). Return to the single shared formulation and choose the symptom cluster that blocks access to the core pain most [synthesis consistent with the modular approach of Timulak & Keogh 2020].
Session limit approaching with core pain untouched. Prioritise:
- at least one compassion or protective-anger experience;
- a clear map the client can use on their own;
- use of the up-to-four-session extension criteria [source for extension: Timulak et al. 2020; rest synthesis].
Intense trauma memories during unrelated work. Contain them, ground the client, put them on the map, and schedule trauma work once the client can regulate [synthesis].
Ending triggers abandonment pain. Announce the ending early, process the feelings it brings up as core pain in the relationship, and consider spaced final sessions. Elliott & Greenberg's case used monthly consolidation sessions [source: Elliott & Greenberg 2016; application synthesis].

Sources

Sources:

Opened but unreadable: the TARA author-accepted full text of the formulation paper (.docx) could not be parsed, and the ISRCTN11430110 page required JavaScript.

Further reading (not drawn on) [uncertain where relied on]:

Timulak, L., & Keogh, D. (2022). Transdiagnostic emotion-focused therapy: A clinical guide for transforming emotional pain. APA.
Timulak, L., & Keogh, D. (2020). Emotion-focused therapy: A transdiagnostic formulation. Journal of Contemporary Psychotherapy.
Timulak, L. (2015). Transforming emotional pain in psychotherapy: An emotion-focused approach. Routledge.
Timulak, L., & McElvaney, J. (2017). Transforming generalized anxiety: An emotion-focused approach. Routledge.
Greenberg, L. S. (2016). Emotion-focused therapy (2nd ed.). APA.
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression. APA.
Watson, J. C., & Greenberg, L. S. (2017). Emotion-focused therapy for generalized anxiety. APA.
Paivio, S. C., & Pascual-Leone, A. (2010). Emotion-focused therapy for complex trauma. APA.
Goldman, R. N., & Greenberg, L. S. (2015). Case formulation in emotion-focused therapy. APA.
Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy. APA.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change. Guilford.

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